Hack, Richard NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
fir This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
f,) Town, Village Regis eyed /, ...,�
Dist. No. wCJ/ County �/t/ or City
(If city, give street address)
Name of deceased 4. t- 7 XtZete eteran (If veteran, give name of War)
Single, married, widowed,
Sex _41..2-&> or divorced (write the word) 441-441 / Date of Death 4.3 — 7 1971,,,
Age �..7 Years ° ont s 7,---2Days Birthplace -
Cause of Death .4 i...Z'?.'` ,--'e
Certificate was signed by 0 .. /Q.�t/ • t , M.D.
�s. .. ...G -d h Address �� o - / U
Place of Burial (or Removal t 47_.c1?"t'� _.�!� �2�-�
(If body is to bp-mporarilly,held till in s ce I er 7
Cemetery t(}.. Date of Burial ... 19,73.
f
(If body is to a temporarily held, fill in space later)
The CERTIFICATE OF DEATH containing the above sta ed particulars, having been presented to me, after careful examination, the
same appe ring to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, hav recorded it in my Local ecord with the ove stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT
4ier,—.
e
the . . . to hold temporarily and the body
( nderta er or person av g charge of core e) (Inter, remove, r otherwise dispose of (state how))
Dated 19 .2J (Signed)
This Permit is sufficient for the Removal (and Interment or Cremation)of a body t o 0eg
StalllliS
le t to cal cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit
Loo. 62 is required.
FORM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
C
Date o ' C � t��Cy� /' was 24%c i /c 19 .,
(Interment or Cremation)
(Name of Cemetery, C-"""'v+�+-arj"rn, e,E_}
S� C/
ion "f1 ce 6'?L'\Lot No. --Grave No. ./-<;
(Signed) ` z �/" .,<.
� ��i
(Person in Charge)
.
Address rc
/� -/' -. x ` -('
{
c r _ - .s-7c -77,7 .77 ,�:
erson in charge must return this Permit to tiegistrar
of his District within SEVEN (7) DAYS from above date. If no
person is in charge, the FUNERAL DIRECTOR or UNDER-
TAKER MUST SIGN ABOVE STATEMENT, write across the
face of the Permit the words "No person in charge," and
FILE PERMIT WITHIN THREE (3) DAYS with the Registrar
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKERS
violating the law relative to the return of permits are liable to
a penalty of NOT LESS THAN FIVE DOLLARS NOR MORE
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.